Faculty Bibliography

PURPOSE:To better understand how anesthesia type impacts patient selection and recovery in TELD, we conducted a multicenter prospective study which evaluates the differences in perioperative characteristics and outcomes between patients who underwent TELD with either general anesthesia (GA) or conscious sedation (CS). METHODS:We prospectively collected data from all TELD performed by five neurosurgeons at five different medical centers between February and October of 2022. The study population was dichotomized by anesthesia scheme, creating CS and GA cohorts. This study's primary outcomes were the Oswetry Disability Index (ODI) and the Visual Analog Scale (VAS) for back and leg pain, assessed preoperatively and at 2-week follow-up. RESULTS:A total of 52 patients underwent TELD for symptomatic lumbar disk herniation. Twenty-three patients received conscious sedation with local anesthesia, and 29 patients were operated on under general anesthesia. Patients who received CS were significantly older (60.0 vs. 46.7, p < 0.001) and had lower BMI (28.2 vs. 33.4, p = 0.005) than patients under GA. No intraoperative or anesthetic complications occurred in the CS and GA cohorts. Improvement at 2-week follow-up in ODI, VAS-back, and VAS-leg was greater in patients receiving CS relative to patients under GA, but these differences were not statistically significant. CONCLUSION:In our multicenter prospective analysis of 52 patients undergoing TELD, we found that patients receiving CS were significantly older and had significantly lower BMI compared to patients under GA. On subgroup analysis, no statistically significant differences were found in the improvement of PROMs between patients in the CS and GA group.

IMPORTANCE:Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population. OBJECTIVE:To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019. DESIGN, SETTING, AND PARTICIPANTS:This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023. MAIN OUTCOME AND MEASURE:The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone. RESULTS:Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001). CONCLUSIONS AND RELEVANCE:In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

BACKGROUND:Ossification of the posterior longitudinal ligament (OPLL) may cause cervical myelopathy. In its multilevel form, it may not be easy to manage. Minimally invasive endoscopic posterior cervical decompression may be an alternative to traditional laminectomy surgery. METHODS:Thirteen patients with multilevel OPLL and symptomatic cervical myelopathy were treated with endoscopic spine surgery from January 2019 to June 2020. In this consecutive observational cohort study, pre- and postoperative Japanese Orthopaedic Association (JOA) score and Neck Disability Index (NDI) were analyzed at a final follow-up of 2 years postoperatively. RESULTS:< 0.001). There were no infections, wound complications, or reoperations. CONCLUSION/CONCLUSIONS:Direct posterior endoscopic decompression for multilevel OPLL is feasible in symptomatic patients when executed at a high skill level. While 2-year outcomes were encouraging and on par with historic data obtained with traditional laminectomy, future studies will need to show whether any long-term shortcomings exist.

BACKGROUND:The microsurgical anterior approach to the cervical spine is commonplace. Fewer surgeons perform posterior cervical microsurgical procedures on a routine basis for lack of indication, more bleeding, persistent postoperative neck pain, and risk of progressive misalignment. In comparison, the endoscopic technique is preferentially performed through the posterior approach. Many spine surgeons and even surgeons versed in lumbar endoscopy are often reluctant to consider endoscopic procedures in the cervical spine. We report the results of a surgeon survey to find out why. METHODS:A questionnaire of 10 questions was sent to spine surgeons by email and chat groups in social media networks including Facebook, WeChat, WhatsApp, and LinkedIn to collect practice pattern data about microscopic and endoscopic spine surgery in the lumbar and cervical spine. The responses were cross-tabulated by surgeons' demographic data. Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances using the statistical package SPSS Version 27.0. RESULTS:The survey response rate was 39.7%, with 50 of the 126 surgeons who started the survey submitting a completed questionnaire. Of the 50 surgeons, 56.2% were orthopedic, and 42% neurological surgeons. Most surgeons worked in private practice (42%). Another 26% were university-employed, 18% were in private practice affiliated with a university, and the remaining 14% were hospital employed. The majority of surgeons (55.1%) were autodidacts. The largest responding surgeon groups were between 35-44 years (38%) and between 45-54 years of age (34%). Half of the responding surgeons were routinely performing endoscopic cervical spine surgery. The other half did not perform it for the main hurdle of fear of complications (50%). Lack of appropriate mentorship was listed as second most reason (25.4%). More concerns for not performing cervical endoscopic approaches were the perception of lack of technology (20.8%) and suitable surgical indication (12.5%). Only 4.2% considered cervical endoscopy too risky. Nearly a third (30.6%) of the spine surgeons treated over 80% of their cervical spine patients with endoscopic surgeries. Most commonly performed were posterior endoscopic cervical discectomy (PECD; 52%), posterior endoscopic cervical foraminotomy (PECF; 48%), anterior endoscopic cervical discectomy (AECD; 32%), cervical endoscopic unilateral laminotomy for bilateral decompression (CE-ULBD; 30%), respectively. CONCLUSION:Cervical endoscopic spine surgery is gaining traction among spine surgeons. However, by far most surgeons performing cervical endoscopic spine surgery work in private practice and are autodidacts. This lack of a teacher to shorten the learning curve as well as fear of complications are two of the major impediments to the successful implementation of cervical endoscopic procedures.

BACKGROUND:Treatment of intermediate-stage painful degenerative disc disease is controversial, with few reliable options. Allogenic mesenchymal stem cells (MSCs)are an alternative to autologous stem cell transplantation. Allogeneic MSCs in the treatment of discogenic low back pain have some practical advantages, ranging from availability to ease of treatment in a procedure-room setting. OBJECTIVES:To assess the efficacy and safety of allogenic MSC injection into painful lumbar intervertebral discs and associated clinical outcomes. STUDY DESIGN:Retrospective observational cohort study. SETTING:Private practice. METHODS:There were 33 patients: 15 women and 18 men with an average age of 47.6 years. The patients' average follow-up was 26.88 months Patients were treated with intradiscal injection of approximately 5 million allogeneic polyclonal MSCs in 1% hyaluronic acid derived from immunoselected umbilical cord stem cells. Patients were monitored for adverse event reactions. Clinical outcomes were assessed with reductions in the reported Visual Analog Scale (VAS) for back pain, the Oswestry Disability Index (ODI) scores, and the use of the modified Macnab criteria. RESULTS:No patient required any additional treatments for low back pain stemming from the level treated with MSC injections. At a 2-year follow-up, the average VAS low back score reduction was 6.565 ± 1.619 and 38.333 ± 14.865 for the ODI (P < 0.001). Reported Macnab outcomes were excellent in 11 patients (33.3%), good in 19 (57.6%), and fair in 3 (9.1%). LIMITATIONS:Our observational study is limited by patient selection, hindsight bias, and low patient numbers. CONCLUSION:The results of our feasibility study suggest that the injection of allogeneic MSCs to treat patients with painful intermediate-stage degenerative disc disease has merit. No adverse reactions were observed. The authors recommend further study in a randomized prospective study setting with a placebo control group or a natural history study group of patients to solidify this research.

Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.

BACKGROUND:Evidence regarding the consequence of efforts to increase patient throughput and decrease length of stay in the context of elective spine surgery is limited. OBJECTIVE:To evaluate whether early time of discharge results in increased rates of hospital readmission or return to emergency department for patients admitted after elective, posterior, lumbar decompression surgery. METHODS:We conducted a retrospective cohort study of 779 patients admitted to hospital after undergoing elective, posterior, lumbar decompression surgery. Multiple logistic regression evaluated the relationship between time of discharge and the primary outcome of return to acute care within 30 days, while controlling for sociodemographic, procedural, and discharge characteristics. RESULTS:In multiple logistic regression, time of discharge earlier in the day was not associated with increased odds of return to acute care within 30 days (odds ratio [OR] 1.18, 95% CI 0.92-1.52, P = .19). Weekend discharge (OR 1.99, 95% CI 1.04-3.79, P = .04) increased the likelihood of return to acute care. Surgeon experience (<1 year of attending practice, OR 0.43, 95% CI 0.19-1.00, P = .05 and 2-5 years of attending practice, OR 0.50, 95% CI 0.25-1.01, P = .054), weekend discharge (OR 0.49, 95% CI 0.27-0.89, P = .02), and physical therapy evaluation (OR 0.20, 95% CI 0.12-0.33, P < .001) decreased the likelihood of discharge before noon. CONCLUSION:Time of discharge is not associated with risk of readmission or presentation to the emergency department after elective lumbar decompression. Weekend discharge is independently associated with increased risk of readmission and decreased likelihood of prenoon discharge.

BACKGROUND:Due to its ultraminimally invasive nature, endoscopic spinal surgery is an attractive tool in spinal oncologic care. To date, there has been no comprehensive review of this topic. The authors therefore present a thorough search of the medical literature on endoscopic techniques for spinal oncology. METHODS:A systematic review using PubMed was conducted using the following keywords: endoscopic spine surgery, spinal oncology, and spinal tumors. RESULTS:Collectively, 19 cases described endoscopic spine surgery for spinal oncologic care. Endoscopic spine surgery has been employed for the care of patients with spinal tumors under the following 4 circumstances: (1) to obtain a reliable tissue diagnosis; (2) to serve as an adjunct during traditional open surgery; (3) to achieve targeted debulking; or (4) to perform definitive resection. These cases employing endoscopic techniques highlight the versatility of this approach and its utility when applied to the right patient and with an experienced surgeon. CONCLUSIONS:Our systematic review suggests that, given the right patient and an experienced surgeon, endoscopic spine surgery should be considered in the armamentarium for spinal oncologic care for both staging and definitive resection. CLINICAL RELEVANCE/CONCLUSIONS:This systematic literature review showed that endoscopic techniques have been successfully applied across the spectrum of care in spinal oncology, from diagnosis to definitive treatment.

The major challenge inherent to the surgical treatment of thoracic disc herniations is that the disc herniation is often ventral to the spinal cord. Posterior approaches are difficult and dangerous due to the morbidity associated with retraction of the thoracic spinal cord. A ventral approach is not feasible due to the thoracic viscera. A lateral transcavitary approach is the standard for treating ventral thoracic disc pathology but is also quite morbid. Transforaminal endoscopic spine surgery has emerged as a minimally invasive technique for treating thoracic disc pathology and it can be performed in the outpatient setting even with the patient awake. Advances in endoscopic camera technologies as well as the availability of specialty instruments that can be used down a working channel endoscope has now made a myriad of spine pathologies accessible to the minimally invasive spine surgeon. The transforaminal approach and the angled endoscopic camera are an ideal combination for creating a technical advantage to accessing thoracic disc pathology in a minimally invasive fashion. The principal challenges to the approach are needle targeting and understanding the endoscopic visual anatomy. Many surgeons interested in pursuing this technique are often deterred by the burden of the cost and time it takes to become adept and performing the technique. Detailed here are the authors' step-by-step technique and illustrative video that demonstrate transforaminal endoscopic thoracic discectomy (TETD).